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PSB-RNSAE practice questions

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Question 1Safe and Effective Care Environment: Management of Care

A newly admitted client with limited English proficiency must sign a consent for a procedure. Which action by the nurse best supports the client's right to informed consent?

  1. Have the client sign the form and explain it afterward
  2. Obtain a qualified medical interpreter for the consent discussion Correct answer.
  3. Document that the client nodded when the procedure was described
  4. Ask the client's adult child to interpret the consent discussion

Explanation

Informed consent requires that the client understand the procedure, risks, and alternatives, so communication must occur in a language the client comprehends. A qualified medical interpreter preserves accuracy and confidentiality, whereas family members may filter information or lack medical vocabulary. Consent obtained without genuine understanding is not valid.

Question 2Safe and Effective Care Environment: Management of Care

A nurse is delegating a task to an unlicensed assistive personnel (UAP). Which task is appropriate to delegate?

  1. Teaching a client to use an incentive spirometer
  2. Obtaining vital signs on a stable postoperative client Correct answer.
  3. Deciding whether to withhold a scheduled medication
  4. Assessing a new report of chest pain

Explanation

Delegation to UAP is limited to tasks that are routine, have predictable outcomes, and do not require nursing judgment. Measuring vital signs on a stable client fits that standard and remains the nurse's responsibility to interpret. Teaching, assessment, and medication decisions require a licensed nurse's clinical judgment.

Question 3Safe and Effective Care Environment: Management of Care

During a shift, a nurse identifies that staffing is inadequate to meet client acuity. What is the nurse's priority management action?

  1. Refuse to provide care until additional staff arrive
  2. Ask UAP to perform assessments to reduce the nurse's workload
  3. Accept the assignment and document concerns at the end of the shift
  4. Escalate the concern through the chain of command per facility policy Correct answer.

Explanation

When staffing does not match acuity, the nurse has an obligation to advocate for client safety by notifying the charge nurse or supervisor per policy. Escalation allows the organization to reallocate resources or adjust assignments. Simply accepting the assignment or abandoning care both place clients at risk.

Question 4Safe and Effective Care Environment: Management of Care

A client asks the nurse to keep information about a new diagnosis confidential from family members. How should the nurse respond?

  1. Explain that hospital policy requires disclosing diagnoses to next of kin
  2. Tell the family because they are involved in the client's care
  3. Honor the client's request and share information only with the client's permission Correct answer.
  4. Share the diagnosis only if the family asks directly

Explanation

Adults with decision-making capacity control disclosure of their protected health information, including to family. The nurse must respect confidentiality unless the client authorizes sharing or a legal exception applies. Family involvement in care does not override the client's right to privacy.

Question 5Safe and Effective Care Environment: Management of Care

A nurse is preparing to administer a medication and notes the order is illegible. What is the most appropriate action?

  1. Clarify the order with the prescriber before administration Correct answer.
  2. Ask a colleague to interpret the handwriting
  3. Administer the medication most consistent with the client's diagnosis
  4. Hold the medication and document the illegible order

Explanation

An illegible or ambiguous order must be clarified with the prescriber before administration to prevent medication errors. Guessing or relying on colleagues' interpretations introduces risk. The nurse is accountable for verifying the order's accuracy.

Question 6Safe and Effective Care Environment: Management of Care

Which action best demonstrates the nurse's role as client advocate during interdisciplinary rounds?

  1. Deferring all decisions to the attending physician
  2. Reporting only objective clinical data during rounds
  3. Presenting the client's stated preferences and concerns to the team Correct answer.
  4. Limiting client input to avoid prolonging the meeting

Explanation

Advocacy involves representing the client's values, preferences, and concerns to the care team so plans reflect the client's wishes. Rounds are an opportunity to ensure the client's voice is included alongside clinical data. Deferring entirely or excluding the client undermines shared decision-making.

Question 7Safe and Effective Care Environment: Management of Care

A nurse manager is assigning clients for the upcoming shift. Which principle should guide the assignment?

  1. Assign clients so each nurse has an equal number regardless of acuity
  2. Give the most complex clients to the newest nurse for experience
  3. Rotate assignments randomly to promote fairness
  4. Match assignments to staff competency and client acuity Correct answer.

Explanation

Safe assignment decisions consider both the acuity and complexity of client needs and the competency of the staff member. Equal numbers or random rotation ignore acuity and skill mix. Assigning the most complex clients to inexperienced staff increases risk.

Question 8Safe and Effective Care Environment: Management of Care

A client with capacity refuses a prescribed blood transfusion. What is the nurse's most appropriate action?

  1. Document the refusal, notify the provider, and continue to monitor the client Correct answer.
  2. Ask the family to sign consent on the client's behalf
  3. Tell the client that refusal will result in discharge
  4. Administer the transfusion because it is life-saving

Explanation

A client with decision-making capacity has the right to refuse treatment, including life-saving interventions. The nurse should respect the refusal, document it, notify the provider, and continue monitoring. Family consent cannot override a capable adult's decision.

Question 9Safe and Effective Care Environment: Management of Care

A nurse receives a telephone order from a provider. What is the priority action after writing the order?

  1. Transcribe the order into the chart without confirmation
  2. Wait until the provider makes rounds to verify the order
  3. Ask another nurse to confirm the order later
  4. Read the order back to the provider for verification Correct answer.

Explanation

Telephone orders carry a high risk of miscommunication, so the nurse must read the order back to the prescriber to verify accuracy. Verification should occur at the time of the call, not later. The order is then documented and signed per policy.

Question 10Safe and Effective Care Environment: Management of Care

A nurse is caring for a client whose condition has deteriorated. The provider is not responding to pages. What is the nurse's best next action?

  1. Continue to page the same provider repeatedly
  2. Activate the rapid response team or chain of command per policy Correct answer.
  3. Ask the client's family to contact the provider
  4. Wait for the next scheduled rounds

Explanation

When a client is deteriorating and the provider is unavailable, the nurse must escalate through rapid response or the chain of command to obtain timely intervention. Repeated paging or waiting delays care. Family members should not be used to obtain urgent medical response.

Question 11Safe and Effective Care Environment: Management of Care

A nurse is admitting a client who speaks limited English. Which action best ensures the client's understanding of discharge instructions?

  1. Ask a bilingual housekeeper to translate the instructions
  2. Provide written instructions in English and ask the client to read them
  3. Use a trained interpreter and confirm understanding with teach-back Correct answer.
  4. Speak more slowly and use hand gestures

Explanation

Trained interpreters and teach-back confirm comprehension and are the standard for limited-English-proficiency clients. Untrained interpreters may misinterpret clinical content. Written English instructions alone do not ensure understanding.

Question 12Safe and Effective Care Environment: Management of Care

A nurse discovers that a colleague appears impaired while preparing medications. What is the nurse's priority action?

  1. Confront the colleague privately and ask them to leave
  2. Report the concern immediately to the charge nurse or supervisor Correct answer.
  3. Ignore the behavior to avoid conflict
  4. Document the observation and address it at the next staff meeting

Explanation

An impaired colleague poses an immediate risk to client safety, so the nurse must report the concern promptly through the appropriate chain of command. The priority is removing the risk from client care. Waiting or handling it privately leaves clients exposed.

Question 13Safe and Effective Care Environment: Management of Care

A client is being discharged and needs home oxygen. Which referral best supports continuity of care?

  1. Referral to the billing department
  2. Case management referral to coordinate equipment and home services Correct answer.
  3. Referral to the hospital chaplain
  4. Social work referral for transportation only

Explanation

Case management coordinates equipment, services, and resources needed for a safe transition home, which supports continuity of care. A single narrow referral does not address the full discharge plan. Billing and spiritual care do not arrange home oxygen or related services.

Question 14Safe and Effective Care Environment: Management of Care

A nurse is prioritizing care for four clients. Which client should the nurse assess first?

  1. A client requesting pain medication for chronic back pain
  2. A client with new shortness of breath and an oxygen saturation of 88% Correct answer.
  3. A client awaiting discharge teaching
  4. A client requesting a snack before bedtime

Explanation

Prioritization follows the ABC framework, so airway and breathing problems take precedence over comfort, teaching, and dietary requests. New hypoxemia signals a potentially life-threatening respiratory problem. The other clients have stable, non-urgent needs.

Question 15Safe and Effective Care Environment: Management of Care

A nurse is assigned a client whose care requires a skill the nurse has not performed. What is the most appropriate action?

  1. Delegate the skill to a UAP
  2. Ask the client to wait until a more experienced nurse is available without notifying anyone
  3. Perform the skill and learn from mistakes
  4. Inform the charge nurse and request supervision or reassignment Correct answer.

Explanation

Nurses are accountable for practicing within their competence, so a skill gap requires notifying the charge nurse to arrange supervision or reassignment. Performing an unfamiliar skill unsupervised risks client harm. UAP cannot perform skills outside their scope.

Question 16Safe and Effective Care Environment: Management of Care

A nurse is preparing to administer a high-alert medication. Which action best reflects the required safety process?

  1. Skip the check if the client has received the medication before
  2. Administer the medication quickly to minimize delay
  3. Rely on memory of the usual dose
  4. Verify with an independent double-check per policy before administration Correct answer.

Explanation

High-alert medications carry a heightened risk of significant harm, so independent double-checks are a standard safeguard. Verification confirms the right dose, route, and client before administration. Memory or prior administration does not substitute for the check.

Question 17Safe and Effective Care Environment: Management of Care

A nurse is caring for a client with suspected abuse. Which action is the priority?

  1. Wait for the provider to report the suspicion
  2. Ensure the client's immediate safety and follow mandatory reporting Correct answer.
  3. Confront the suspected abuser
  4. Ask the client to leave the facility

Explanation

The first priority is protecting the client from further harm, followed by following state mandatory reporting laws. Confronting a suspected abuser may escalate danger. Reporting is the nurse's legal responsibility and should not be deferred.

Question 18Safe and Effective Care Environment: Management of Care

A nurse is reviewing a client's advance directive. The client has designated a health care proxy. What does this designation mean?

  1. The proxy must approve all nursing interventions during the current admission
  2. The proxy can make health care decisions if the client loses capacity Correct answer.
  3. The proxy replaces the client's physician
  4. The proxy inherits the client's financial assets

Explanation

A health care proxy is a person authorized to make health care decisions on the client's behalf if the client becomes unable to do so. The proxy does not manage finances or replace the provider. Routine nursing care does not require proxy approval while the client has capacity.

Question 19Safe and Effective Care Environment: Management of Care

A nurse is preparing to transfer a client to another unit. Which action best supports continuity of care?

  1. Send the client without a report to save time
  2. Provide a structured handoff report including current status and pending items Correct answer.
  3. Transfer during shift change to reduce interruptions
  4. Rely on the receiving nurse to read the chart

Explanation

A structured handoff communicates the client's current status, risks, and pending tasks so the receiving nurse can continue safe care. Omitting report or relying on chart review alone risks gaps. Transfers during shift change increase the chance of miscommunication.

Question 20Safe and Effective Care Environment: Management of Care

A nurse identifies a recurring medication error on the unit. Which action best reflects quality improvement?

  1. Punish the nurse involved to prevent recurrence
  2. Ignore the pattern because errors are rare
  3. Report the error and participate in a root cause analysis Correct answer.
  4. Document the error without further action

Explanation

Quality improvement requires reporting errors and analyzing system causes, such as through root cause analysis, to prevent recurrence. Blame-focused responses discourage reporting. Documenting without analysis leaves the underlying system problem unaddressed.

Question 21Safe and Effective Care Environment: Management of Care

A nurse is caring for a client with an airborne infection who needs transport. Which action best supports infection control management?

  1. Place a surgical mask on the client and notify the receiving department Correct answer.
  2. Transport the client without a mask through crowded areas
  3. Ask the receiving department to prepare after arrival
  4. Remove the client's isolation precautions during transport

Explanation

Source control with a mask on the client and advance notification to the receiving area reduces transmission during transport. Removing precautions or moving through crowded areas increases exposure risk. Advance notice allows the receiving department to prepare appropriate precautions.

Question 22Safe and Effective Care Environment: Management of Care

A nurse is managing care for a client with multiple providers. Which action best prevents conflicting treatment plans?

  1. Allow each provider to order independently without coordination
  2. Ask the client to resolve conflicting orders
  3. Coordinate care through interdisciplinary communication and shared planning Correct answer.
  4. Delay implementation until discharge

Explanation

Coordinated interdisciplinary communication and shared care planning reduce duplication and conflicting orders. Allowing independent ordering without coordination increases risk. The client should not be responsible for resolving provider conflicts, and delay can harm the client.

Question 23Safe and Effective Care Environment: Management of Care

A nurse is supervising a student who is about to perform a procedure. Which action best reflects appropriate supervision?

  1. Leave the student alone to build confidence
  2. Verify the student's preparation and remain available to intervene Correct answer.
  3. Ask the client to supervise the student
  4. Allow the student to perform the procedure unsupervised if they have read about it

Explanation

Supervision requires confirming the student's preparation and remaining available to intervene to protect client safety. Unsupervised practice by a learner who has not been verified exceeds safe delegation. Clients cannot supervise learners.

Question 24Safe and Effective Care Environment: Management of Care

A nurse is caring for a client who lacks decision-making capacity and has no advance directive. Which action best guides care decisions?

  1. Delay all care until the client regains capacity
  2. The nurse decides based on personal values
  3. The provider decides without involving others
  4. Use the facility's ethics process and identify a surrogate decision-maker per policy Correct answer.

Explanation

When a client lacks capacity and has no directive, decisions should follow the facility's ethics process and involve a legally recognized surrogate decision-maker. Personal values or unilateral provider decisions do not reflect the client's interests. Delaying all care may cause harm.

Question 25Safe and Effective Care Environment: Management of Care

A nurse is reviewing a client's record and finds that a colleague documented an assessment that was never performed. What is the nurse's priority action?

  1. Ignore the entry to avoid conflict
  2. Add a note supporting the colleague's entry
  3. Report the falsified documentation to the supervisor Correct answer.
  4. Confront the colleague in front of the client

Explanation

Falsified documentation is a serious patient-safety and legal issue that must be reported to a supervisor so the record can be corrected and the client reassessed. Ignoring or supporting the entry perpetuates the error. Confrontation in front of the client is inappropriate.

Question 26Safe and Effective Care Environment: Management of Care

A nurse is preparing to administer a scheduled medication to a client. Which action best demonstrates the nurse's responsibility in the management of care?

  1. Check the medication against the previous shift's documentation.
  2. Ask the client to confirm the medication name and dose.
  3. Administer the medication and document it after completing the rounds.
  4. Verify the client's identity using two identifiers before administration. Correct answer.

Explanation

Using two client identifiers (e.g., name and date of birth) is a standard safety practice to prevent medication errors and is a core management-of-care responsibility. It ensures the right client receives the right medication. The other options either rely on the client's knowledge, which is unsafe, or delay documentation, which risks errors.

Question 27Safe and Effective Care Environment: Management of Care

A nurse is delegating a task to a nursing assistant. Which task is appropriate for the nurse to delegate?

  1. Performing a sterile dressing change on a surgical wound.
  2. Assessing a client's new onset of shortness of breath.
  3. Administering a PRN pain medication to a postoperative client.
  4. Assisting a stable client with a bed bath. Correct answer.

Explanation

Delegation to unlicensed assistive personnel (UAP) is appropriate for tasks that are routine, stable, and have predictable outcomes, such as assisting with hygiene. The nurse retains responsibility for assessment, teaching, and evaluation. Sterile procedures, medication administration, and assessment require a licensed nurse.

Question 28Safe and Effective Care Environment: Management of Care

A nurse is caring for a client who is scheduled for surgery. The client asks the nurse to explain the procedure again. Which action best supports the client's right to informed consent?

  1. Witness the client's signature on the consent form without further discussion.
  2. Notify the surgeon that the client has questions about the procedure. Correct answer.
  3. Give the client a brochure about the surgery and document the teaching.
  4. Provide the explanation and ask the client to sign the consent form.

Explanation

Informed consent requires that the provider performing the procedure explain its risks, benefits, and alternatives. The nurse's role is to verify understanding and ensure the client has the information needed to make an informed decision. If the client has questions, the nurse should contact the surgeon to provide clarification.

Question 29Safe and Effective Care Environment: Management of Care

A nurse is reviewing a client's medication administration record and notices that a dose of insulin is due at 0800. The client's blood glucose is 60 mg/dL. Which action should the nurse take first?

  1. Document the low glucose and administer the insulin at a reduced dose.
  2. Hold the insulin and notify the provider of the low blood glucose. Correct answer.
  3. Administer the insulin as prescribed and monitor the client.
  4. Give the client a carbohydrate snack and recheck glucose in 30 minutes.

Explanation

The nurse must recognize that administering insulin to a client with hypoglycemia (blood glucose 60 mg/dL) could be dangerous. The priority is to hold the insulin and notify the provider for further orders. The nurse should also treat the hypoglycemia per protocol, but the first action is to withhold the insulin and escalate.

Question 30Safe and Effective Care Environment: Management of Care

A nurse manager is planning staff assignments for the next shift. Two clients require frequent monitoring: one with a new tracheostomy and one with a fresh colostomy. Which assignment is most appropriate?

  1. Assign the tracheostomy client to a nursing assistant and the colostomy client to a licensed practical nurse.
  2. Assign the tracheostomy client to an experienced nurse and the colostomy client to a nurse with less experience. Correct answer.
  3. Assign both clients to a float nurse from another unit.
  4. Assign both clients to a nurse with less experience to build competence.

Explanation

The nurse manager should match client needs with staff competence. A new tracheostomy requires a nurse skilled in airway management, so an experienced nurse is appropriate. The colostomy client's needs can be met by a nurse with less experience under supervision, promoting skill development while maintaining safety.

Question 31Safe and Effective Care Environment: Management of Care

A nurse is caring for a client who is confused and repeatedly attempts to get out of bed. The nurse has implemented fall precautions. Which action should the nurse take next to best manage the client's safety?

  1. Apply physical restraints to prevent the client from falling.
  2. Increase the frequency of rounding and involve family in supervision. Correct answer.
  3. Ask the provider for a sedative to keep the client calm.
  4. Place the client in a room closest to the nurses' station and raise all four side rails.

Explanation

The least restrictive interventions should be used first to manage fall risk in a confused client. Increasing rounding and involving family can help supervise the client without restraining or sedating. Restraints and sedatives carry significant risks and require specific criteria and orders.

Question 32Safe and Effective Care Environment: Management of Care

A nurse is preparing to discharge a client who requires ongoing wound care. Which action best ensures continuity of care?

  1. Give the client the nurse's phone number for questions after discharge.
  2. Document the discharge teaching in the client's record.
  3. Provide the client with written instructions and a follow-up appointment.
  4. Arrange a home health referral and verify the client's understanding of the plan. Correct answer.

Explanation

Continuity of care for a client with ongoing wound care requires coordination with home health services and confirmation that the client understands the plan. This ensures the necessary resources are in place after discharge. Written instructions and documentation are important but do not by themselves ensure services are arranged.

Question 33Safe and Effective Care Environment: Management of Care

A nurse is reviewing a client's plan of care and notes that the client's pain is not well controlled despite the current interventions. Which action should the nurse take first?

  1. Ask the client to rate the pain on a scale of 0 to 10 and wait for the next scheduled dose.
  2. Consult with the provider to explore alternative pain management options. Correct answer.
  3. Document that the pain is unresolved and continue the current plan.
  4. Revise the plan of care independently to include a different medication.

Explanation

When a client's pain is not controlled, the nurse should collaborate with the provider to adjust the plan of care. This may include changing medications or adding complementary therapies. The nurse cannot independently change medication orders, and simply documenting or waiting does not address the client's needs.

Question 34Safe and Effective Care Environment: Management of Care

A nurse is caring for a client who has just returned from surgery. The client's spouse asks the nurse about the client's prognosis. The client has not authorized the nurse to share information with the spouse. Which action should the nurse take?

  1. Provide general information about the surgery and expected recovery.
  2. Ask the spouse to wait until the client is more alert and then discuss it with the client.
  3. Explain that the nurse cannot discuss the client's condition without permission and offer to ask the client. Correct answer.
  4. Refer the spouse to the surgeon for any information.

Explanation

The nurse must protect the client's privacy under HIPAA. Without the client's authorization, the nurse cannot disclose health information to the spouse, even if the spouse is asking. The nurse should explain the confidentiality policy and offer to obtain the client's permission to share information.

Question 35Safe and Effective Care Environment: Safety and Infection Control

A nurse is preparing to insert a peripheral IV catheter. Which action best demonstrates adherence to standard precautions during the procedure?

  1. Don gloves only after the catheter has been inserted and secured
  2. Perform hand hygiene and don clean gloves before palpating the intended site Correct answer.
  3. Wear sterile gloves throughout because the procedure breaks the skin
  4. Apply a tourniquet and palpate the site with bare hands before cleansing

Explanation

Standard precautions require hand hygiene and gloves whenever contact with blood or body fluids is anticipated; inserting a catheter carries that risk. Clean gloves are appropriate for peripheral IV insertion, and sterile gloves are not required for this procedure.

Question 36Safe and Effective Care Environment: Safety and Infection Control

Which client requires contact precautions in addition to standard precautions?

  1. A client receiving nebulized bronchodilator therapy
  2. A client with an active Clostridioides difficile infection Correct answer.
  3. A client with chronic hepatitis C and no bleeding
  4. A client with a healing surgical incision and no drainage

Explanation

Clostridioides difficile is spread by spores that contaminate surfaces and hands, so contact precautions are required along with standard precautions. Hepatitis C and a dry, healing incision do not require transmission-based precautions in routine care.

Question 37Safe and Effective Care Environment: Safety and Infection Control

A client with pulmonary tuberculosis is being transported to radiology. Which action should the nurse take to protect others during transport?

  1. Have the client wear a high-efficiency particulate air (HEPA) respirator during transport
  2. Place a surgical mask on the client and keep the transport as brief as possible Correct answer.
  3. Ask radiology staff to enter the room without respiratory protection
  4. Remove the client's mask once the client leaves the negative-pressure room

Explanation

A client with active pulmonary tuberculosis who must leave an airborne infection isolation room should wear a surgical mask to contain respiratory droplets and secretions. Transport should be limited to essential purposes to reduce exposure of others.

Question 38Safe and Effective Care Environment: Safety and Infection Control

When performing hand hygiene with an alcohol-based hand rub, which technique is correct?

  1. Apply the product only to the palms and fingertips
  2. Wipe the product off with a paper towel after ten seconds
  3. Rinse the hands with water after the product dries
  4. Apply product to dry hands, rub all surfaces until the hands feel dry Correct answer.

Explanation

Alcohol-based hand rub should be applied to dry hands and rubbed over all surfaces of the hands and fingers until they are dry. Rubbing until dry allows the product to achieve adequate antimicrobial effect.

Question 39Safe and Effective Care Environment: Safety and Infection Control

A nurse is caring for a client with a new tracheostomy. Which action reduces the risk of infection during suctioning?

  1. Instill normal saline routinely before each suction pass
  2. Reuse the same catheter for the entire shift after rinsing it with tap water
  3. Use sterile technique and single-use suction catheters for each pass Correct answer.
  4. Suction for at least thirty seconds on each pass to clear secretions

Explanation

Tracheostomy suctioning enters the lower airway, so sterile technique with a single-use catheter prevents introducing organisms. Routine saline instillation and prolonged suctioning are not recommended and increase harm.

Question 40Safe and Effective Care Environment: Safety and Infection Control

A client is on droplet precautions. Which personal protective equipment is required when entering the room to provide routine care?

  1. A gown and gloves only, without a mask
  2. No protective equipment if the door remains open
  3. A surgical mask in addition to standard precautions Correct answer.
  4. A HEPA respirator and a full face shield

Explanation

Droplet precautions require a surgical mask when within close range of the client, in addition to standard precautions such as gloves and gown when contact is anticipated. A HEPA respirator is reserved for airborne precautions.

Question 41Safe and Effective Care Environment: Safety and Infection Control

A nurse receives a needlestick injury from a contaminated hollow-bore needle. Which action should the nurse take first?

  1. Wait for the source client's test results before reporting
  2. Apply a tight tourniquet above the puncture site
  3. Squeeze the puncture site firmly to express blood
  4. Wash the site with soap and water and report the exposure immediately Correct answer.

Explanation

After a needlestick, the site should be washed with soap and water and the exposure reported immediately so post-exposure evaluation and prophylaxis can begin. Squeezing or applying a tourniquet is not recommended.

Question 42Safe and Effective Care Environment: Safety and Infection Control

Which action by a nurse best prevents catheter-associated urinary tract infection in a client with an indwelling catheter?

  1. Disconnecting the tubing to obtain urine samples routinely
  2. Irrigating the catheter daily with an antiseptic solution
  3. Routinely changing the catheter every forty-eight hours
  4. Maintaining a closed drainage system and keeping the bag below bladder level Correct answer.

Explanation

A closed drainage system with the bag below bladder level prevents backflow of contaminated urine into the bladder. Routine irrigation, unnecessary disconnection, and fixed frequent catheter changes are not recommended prevention measures.

Question 43Safe and Effective Care Environment: Safety and Infection Control

A nurse is preparing to administer a unit of packed red blood cells. Which action is most important before starting the transfusion?

  1. Begin the transfusion at a rapid rate to save time
  2. Prime the tubing with dextrose 5% in water
  3. Verify the client and blood product with a second qualified person at the bedside Correct answer.
  4. Obtain a urine specimen after the first fifteen minutes

Explanation

Bedside verification of the client and the blood product by two qualified staff is essential to prevent a hemolytic transfusion reaction. Only compatible intravenous fluids should be used, and the transfusion must start slowly with monitoring.

Question 44Safe and Effective Care Environment: Safety and Infection Control

A client is admitted with suspected active pulmonary tuberculosis. Which isolation measure should the nurse implement?

  1. Standard precautions with no additional room requirements
  2. Contact precautions with gown and gloves only
  3. Droplet precautions with a surgical mask and the door left open
  4. Airborne precautions in a negative-pressure room with a HEPA respirator for staff Correct answer.

Explanation

Pulmonary tuberculosis is transmitted by airborne droplet nuclei, so airborne precautions in a negative-pressure room with staff wearing a fit-tested HEPA respirator are required. Droplet and contact precautions alone do not protect against airborne transmission.

Question 45Safe and Effective Care Environment: Safety and Infection Control

A nurse is preparing to administer a medication via a peripheral IV line. Which action reflects safe practice for preventing infection?

  1. Reuse the same needleless connector for multiple clients
  2. Wipe the hub with an alcohol swab and immediately attach the syringe
  3. Leave the hub uncapped between medication administrations
  4. Scrub the access hub with an antiseptic for the recommended contact time before use Correct answer.

Explanation

Scrubbing the access hub with an antiseptic and allowing the recommended contact time, often called scrub the hub, reduces contamination of the catheter system. Immediate attachment without drying time limits the antiseptic's effect.

Question 46Safe and Effective Care Environment: Safety and Infection Control

A client with an active Clostridioides difficile infection has a stool spill on the floor. Which cleaning agent should the nurse use?

  1. A chlorine-based disinfectant effective against spores Correct answer.
  2. An alcohol-based hand rub applied to the surface
  3. Plain soap and water without disinfectant
  4. A quaternary ammonium compound alone

Explanation

Clostridioides difficile produces spores that survive many routine disinfectants, so a chlorine-based sporicidal disinfectant is recommended for environmental cleaning. Alcohol does not reliably kill spores and is not a surface cleaner.

Question 47Safe and Effective Care Environment: Safety and Infection Control

A nurse is caring for a client with an order for protective environment precautions. Which action is appropriate?

  1. Keep the room door open to allow air circulation
  2. Place the client in a room with positive-pressure airflow and avoid fresh flowers Correct answer.
  3. Use a surgical mask instead of a HEPA respirator for all staff
  4. Allow visitors to bring potted plants into the room

Explanation

Protective environment precautions protect immunocompromised clients by using positive-pressure airflow and avoiding sources of environmental organisms such as fresh flowers and standing water. The room door is kept closed to maintain pressure relationships.

Question 48Safe and Effective Care Environment: Safety and Infection Control

A nurse is teaching a client and family about home management of a multidrug-resistant wound infection. Which instruction is most important?

  1. Perform hand hygiene before and after touching the wound or dressing Correct answer.
  2. Store used dressings in an open trash can in the kitchen
  3. Share towels with family members to conserve laundry
  4. Stop antibiotics when the wound stops draining

Explanation

Hand hygiene before and after wound care is the single most effective way to prevent spread of multidrug-resistant organisms in the home. Antibiotics must be completed as prescribed, and contaminated dressings should be bagged and disposed of safely.

Question 49Safe and Effective Care Environment: Safety and Infection Control

A client is receiving a blood transfusion and develops fever, chills, and flank pain fifteen minutes after the start. What should the nurse do first?

  1. Increase the flow rate to finish the unit more quickly
  2. Stop the transfusion and maintain IV access with normal saline Correct answer.
  3. Slow the transfusion and reassess in thirty minutes
  4. Administer the prescribed antipyretic and continue the transfusion

Explanation

Fever, chills, and flank pain suggest an acute hemolytic transfusion reaction, which requires immediately stopping the transfusion while keeping the line patent with normal saline. The provider and blood bank are then notified and the reaction is investigated.

Question 50Safe and Effective Care Environment: Safety and Infection Control

Which nursing action is correct when removing personal protective equipment after caring for a client on contact precautions?

  1. Remove gloves first, then the gown, then perform hand hygiene before removing the mask Correct answer.
  2. Remove the gown before the gloves and then touch the face
  3. Remove the mask first while still wearing contaminated gloves
  4. Remove all equipment in any order without hand hygiene

Explanation

Gloves and gown are removed first because they are most contaminated, followed by hand hygiene, and the mask is removed last by the ties without touching the front. Hand hygiene is performed again after all equipment is removed.